Provider Demographics
NPI:1487647657
Name:MONGER, BROCK (DPT)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:MONGER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 SW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-1341
Mailing Address - Country:US
Mailing Address - Phone:541-475-1218
Mailing Address - Fax:541-475-7647
Practice Address - Street 1:230 SW 5TH ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1341
Practice Address - Country:US
Practice Address - Phone:541-475-1218
Practice Address - Fax:541-475-7647
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4945893-2401225100000X
OR5164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP81416Medicare UPIN